Persius/hicric huggingface dataset:
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the CardioMEMS procedure. 
 
You asked the Plan to pre-approve the CardioMEMS procedure. You say that the CardioMEMS device is 
indicated for this patient. The Plan denied your request. The Plan says the CardioMEMS procedure is 
considered experimental/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 CardioMEMS procedure. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the CardioMEMS device was approved by the Food and Drug 
Administration (FDA) in 2014 and consists of a sensor device placed in the pulmonary artery to allow 
measurement of pulmonary artery pressure in the management of patients with congestive heart failure (CHF). The clinical study on which FDA approval was based showed improved clinical outcomes and decreased 
hospitalizations in patients in whom the CardioMEMS system was implanted, reflecting a patient population 
with preserved ejection fraction and was somewhat limited in scope. Subsequent follow-up studies remain 
encouraging and suggest an improvement in heart failure symptoms with the use of the device. In addition, 
published expert opinion in the cardiology literature is supportive of the clinical usefulness of 
CardioMEMS.  Nonetheless, there remains a dearth of randomized, blinded clinical studies examining long-
term clinical outcomes establishing the value of CardioMEMS in patient management. As a result, at this time 
the CardioMEMS system would not be considered medically appropriate and necessary in this patients clinical 
management. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the CardioMEMS procedure have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the CardioMEMS procedure.
Appeal type: Step-Therapy
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Retacrit (epoetin-alfa-epbx). 
 You asked the Plan to pre-approve the Retacrit treatments. You say that the Plan preferred drugs cost more than 
the reimbursement rates for your office. The Plan denied your request. The Plan says the Plan requires a trial of 
preferred drugs before approving Retacrit. 
 
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 Retacrit treatments. Our reviewer 
says that the requested drug is not considered medically necessary based on step therapy rules. Our physician 
reviewer found the Plan requires a trial of drug Aranesp or Procrit before they will approve the requested drug. 
In this case, the enrollee has 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 
the enrollee. 
 
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 Retacrit treatments have not been met. Therefore, we decided that the Plan 
does not have to pre-approve Retacrit (epoetin-alfa-epbx).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve anesthesia intraoral with biopsy (00170) and unlisted 
procedure dentoalveolar structures (41899). 
 
You asked the Plan to pre-approve anesthesia intraoral with biopsy and unlisted procedure dentoalveolar 
structures. You say that this is medically necessary. The Plan denied your request. The Plan says this is not a 
covered benefit under the medical plan. 
 
Medicare generally does not cover dental services. The Plan follows the same rule. 
 
The services you are asking the Plan to pre-approve involve the care, treatment, filling, removal or replacement 
of the enrollees teeth or the structures directly supporting the enrollees teeth. These are dental services that 
are not covered or paid for by Medicare. Therefore, we decided that the Plan does not have to pre-approve 
anesthesia intraoral with biopsy (00170) and unlisted procedure dentoalveolar structures (41899).
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. The Plan denied your request. The Plan says the records do not 
support the services requested, services needed is help with self-care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: 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 you fell and injured you knee, and you are your 
husbands caretaker. The Plan denied your request. The Plan says your medical condition is stable, medically 
necessary care may be provided safely in a lower level of care. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: 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. The Plan denied your request. The Plan says the guidelines and 
the information we have about the enrollee's condition, it does not meet all of the requirements. 
 
The Plan must follow Medicare rules. The rules say that IRF admission is covered only when it is medically 
reasonable and necessary as described in the Medicare rules section. 
 
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to determine if the Plan was correct in denying the request to pre-approve IRF care. Our reviewer says that the 
requested IRF care is not considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the complexity of the enrollee's nursing, medical and rehabilitation needs does not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IRF care have not been met. Therefore, we decided that the Plan does not have 
to pre-approve acute inpatient rehabilitation facility (IRF) admission and services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Group 3 power wheelchair (K0857) and accessories. 
 
You asked the Plan to pre-approve a power wheelchair and accessories. You say that the requested items are 
medically necessary. The Plan denied your request. The Plan says that the power wheelchair and accessories 
are not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that a PMD will not be covered if the patient does not 
have mobility deficit that impairs their participation in MRADLs, the patient's condition can be ameliorated by 
a walker, cane or manual wheelchair, or the patient is not capable of safely operating the requested PMD.  
 
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 power wheelchair and accessories. 
Our reviewer says that the coverage criteria has not been met. Our physician reviewer found that you are not at 
high risk for skin breakdown, do not use a catheter, and do not have spasticity. As the requested power 
wheelchair base is not medically necessary, the requested accessories are not covered. 
 
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 power wheelchair and accessories have not been met. Therefore, we decided 
that the Plan does not have to pre-approve a Group 3 power wheelchair (K0857) and accessories.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve quick release push handles and removable clothing 
guard. 
 
You asked the Plan to pre-approve quick release push handles and removable clothing guard. You say that you 
want the Plan to cover these items. The Plan denied your request. The Plan says these items are convenience 
items. They are not medically necessary. 
 
The Plan must follow Medicare rules. The rules say that for equipment to be covered, it must primarily serve a 
medical purpose.   
 
The item at issue in this appeal does not serve a purpose that is primarily medical in nature. This item is 
available to the general public and would be helpful even to those who are not sick or injured. Therefore, we 
decided that the Plan does not have to pre-approve quick release push handles and removable clothing guard.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Image-Guided, Intensity-Modulated Radiation Therapy 
(IG-IMRT) (77385, 77387) x24. 
 
You asked the Plan to pre-approve IG-IMRT x24. 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 IG-IMRT x24. Our reviewer says that 
the requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found based on the medical records provided and the guidelines of the National Comprehensive 
Cancer Network there is no documentation that the IG-IMRT x24 at issue in this case meets all Medicare 
criteria for medically reasonable and necessary for the enrollee. The guidelines of the National Comprehensive 
Cancer Network support 20 fractions of external beam radiation therapy for low volume M1 prostate cancer. 
No support can be found in the guidelines for the IG-IMRT x24 at issue in this case. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of IG-IMRT x24 have not been met. Therefore, we decided that the Plan does not 
have to pre-approve Image-Guided, Intensity-Modulated Radiation Therapy (IG-IMRT) (77385, 77387) x24.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for the SelectMDx testing provided to the enrollee on April 26, 2022.
You asked the Plan to pay for the SelectMDx testing. You say that the testing distinguishes those at increased risk for prostate cancer. The Plan denied your request. The Plan says you billed with an incorrect place of service on the claim.
Maximus overturned the Plans denial. The Plan requested a reopen and stated the issue was not medical necessity issue but the fact that the claim was submitted with an error. The claim was billed with a place of service (POS) 81, Independent Laboratory, independent of an institution or a physician's office. An independent laboratory taking a sample in its laboratory shows "81" as place of service, however, the specimen was not collected in an independent laboratory. 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 cannot be paid as billed due to error with the POS code reported. Medicare rules for coverage of this testing have not been met. Therefore, we decided that the Plan does not have to pay for the SelectMDx testing provided to the enrollee on April 26, 2022.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve medial branch block at a third level (bilateral L4-L5). 
 
You asked the Plan to pre-approve medial branch block at a third level (bilateral L4-L5). You say that you 
disagree with the Plan's denial. The Plan denied your request. The Plan says the requested services are not 
medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that one to two levels, either unilateral or bilateral, 
are allowed per session per spine region. 
 
We looked at the file and Medicare rules. Review of the file shows that three levels are being requested for one 
session. Medicare rules only allow one or two levels. This means a third level is not a covered benefit. Based 
on this information, we decided that Medicare rules for coverage of medial branch block at a third level 
(bilateral L4-L5) have not been met. Therefore, we decided that the Plan does not have to pre-approve medial 
branch block at a third level (bilateral L4-L5).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the upgraded electronics (E2311, E2377, E2313), power 
seat elevation feature (E2300), and sliding back canes (K0108). 
 
You asked the Plan to pre-approve the upgraded electronics, power seat elevation feature, and sliding back 
canes. You say that the requested items are medically necessary. The Plan denied your request. The Plan says 
that the upgraded electronics are not medically necessary to control the power options through the joystick. 
 
The Plan follows Medicare rules. Medicare rules say that the upgraded electronics are covered when it is 
medically necessary for the enrollee to control the power options through the joystick. The rules also say a 
power seat elevation feature is not covered as it is not primary medical in nature. 
 
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 upgraded electronics. Our reviewer 
says that the coverage criteria has not been met. Our physician reviewer found that the enrollee adequate 
strength to manage the standard switches on a power wheelchair. 
 
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 upgraded electronics have not been met. A power seat elevation feature 
(E2300) is not covered as it is not primarily medical in nature. Sliding back canes (K0108) are not separately 
payable as they are included with the approved power tilt and recline (E1007). Therefore, we decided that the 
Plan does not have to pre-approve the upgraded electronics (E2311, E2377, E2313), power seat elevation 
feature (E2300), and sliding back canes (K0108).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an osteoinductive allograft. 
 
You asked the Plan to pre-approve these services. You say that you disagree with the denial. The Plan denied 
your request. The Plan says the services are 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the use of an iliac crest autograft is the 
gold standard for the approved surgery. The requested osteoinductive allograft is not the standard of care and is 
not reasonable or medically necessary.  

We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of these services have not been met. Therefore, we decided that the Plan does not 
have to pre-approve an osteoinductive allograft.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve cataract eye surgery and associated procedures (66984, 65865, 66174) to be provided by an out-of-network (OON) provider.

You asked the Plan to pre-approve cataract eye surgery and associated procedures to be provided by an OON provider. You say that the services are necessary. The Plan denied your request. The Plan says there are in-network providers that are able to provide these services. Therefore, coverage criteria 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 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 cataract eye surgery and associated procedures (66984, 65865, 66174) to be provided by an out-of-network (OON) provider.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the observation care discharge day management (99217) 
provided on September 28, 2022. 
 
You asked the Plan to pay for the service. You say that the medical records support the billing of code 99217. 
The Plan denied your request. The Plan says the medical records do not support the billing of code 99217. 
 
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 99217 is observation care discharge day management 
(This code is to be utilized to report all services provided to a patient on discharge from outpatient hospital 
"observation status" if the discharge is on other than the initial date of "observation status." To report services 
to a patient designated as "observation status" or "inpatient status" and discharged on the same date, use the 
codes for Observation or Inpatient Care Services [including Admission and Discharge Services, 99234-99236 as appropriate.]) 
 
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 service. Our reviewer found the documentation submitted 
was reviewed and does not meet criteria. Initial care does not include documentation to support observation 
care. Record documents "emergency department to Hosp-Admission (Discharged) on September 27, 2022".  
The medical record does not include status of inpatient serve and therefore cannot be verified. 
 
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 service have not been met. Therefore, we decided that the Plan does not 
have to pay for the observation care discharge day management (99217) provided on September 28, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a power seat elevation system (E2300) along with an 
expandable controller (E2377) with related hardware (E2313) and electronic connections (E2311). 
 
You asked the Plan to pre-approve the expandable controller items and power seat elevator. You say that the 
requested items are medically needed. The Plan denied your request. The Plan says the power seat elevator is 
not covered by Medicare. In addition, there is no medical need for the expandable controller. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered. The rules also say that power seat elevation systems on a power wheelchair are noncovered. 
 
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 expandable controller items and 
power seat elevator. Our reviewer says that the requested items are not considered medically reasonable and 
necessary in this case. Our physician reviewer found the documentation does not support that it is medically 
necessary to control the requested power options through the joystick (drive interface). The enrollee's 
upper functional ability as evidenced by being independent for feeding should be sufficient to control any 
power options through their own switches. 
 
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 expandable controller items and power seat elevator have not been met. 
Therefore, we decided that the Plan does not have to pre-approve a power seat elevation system (E2300) along 
with an expandable controller (E2377) with related hardware (E2313) and electronic connections (E2311).