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

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that IRF care is a medical necessity for you. The Plan 
denied your request. The Plan says rules for IRF care have not been met. 
 
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 that the complexity of your nursing, medical and rehabilitation needs does not require 
an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. You are currently 
receiving outpatient medical management and do not require the intensity of rehabilitation physician oversight provided in the acute inpatient rehabilitation setting. Your medical and rehabilitation needs do not require the 
intensive interdisciplinary approach provided on acute inpatient rehabilitation. 
 
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 IRF admission and services.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee meets IRF admission criteria, and their 
ongoing rehabilitative needs warrant an IRF level of care to achieve a safe and sustainable discharge. The Plan 
denied your request. The Plan says criteria for admission to the IRF have not been met. 
 
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 do not 
require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. 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 IRF admission and services.
Appeal type: Imaging
Decision: Unfavorable

We decided the Plan does not have to provide coverage for a computed tomography (CT) scan for the abdomen and pelvis.
You asked the Plan to provide coverage for this imaging. You say that at the time of the appeal, this imaging was medically necessary. The Plan denied your request. The Plan says the Medicare coverage criteria were not met. Maximus overturned the Plans denial stating this imaging is covered every six months. The Plan requested a reopen noted you previously had a CT of the abdomen and pelvis on May 18, 2022, which was only 3 months prior to this appealed request. As confirmed by the original Maximus review, the NCCN guideline is for imaging every 6 months. Therefore, the denial of this service was correct.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that CT scans are covered only when they are medically necessary. In this case, this imagine was requested within three months of the previous imaging. This specific imaging is covered every six months. Medicare rules for coverage of this imaging have not been met. Therefore, we decided that the Plan does not have to provide coverage for a computed tomography (CT) scan for the abdomen and pelvis.
Appeal type: SNF
Decision: Favorable

 
We decided that the Plan has to pre-approve skilled nursing facility (SNF) care. 
 
You asked the Plan to pre-approve SNF care. You say that the services are necessary. The Plan denied your 
request. The Plan says that based on the documentation provided, coverage criteria has 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 care. Our reviewer says that the 
requested SNF care is considered medically reasonable and necessary based on Medicare guidelines. Our 
physician reviewer found the health plan has denied ongoing SNF coverage. This denial has apparently been 
based on records from December 2, 2022, December 3, 2022, December 20, 2022, December 28, 2022 and 
January 4, 2023. These records have not been identified by the IRE. As such, the health plan has failed to 
support its denial. 
 
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 been met. The Plan must continue coverage for the SNF skilled 
service until such time as the enrollee no longer needs the service and proper notice has been issued, or the 
100-day Medicare benefit is exhausted. Therefore, we decided that the Plan has to pre-approve skilled nursing 
facility (SNF) care.  
 
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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the tetanus, diphtheria toxoids and acellular pertussis vaccine 
(TDAP) (90715) provided on July 28, 2022. 
 
You asked the Plan to pay for the TDAP vaccine. You say that you received this vaccine at your doctor's office 
because you were advised by your doctor to get it, and you feel it should be covered. The Plan denied your 
request. The Plan says this service is not covered under your medical benefit, but may be eligible under your 
prescription drug benefit. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide the TDAP vaccine. 
The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to the TDAP vaccine. 
Therefore, we decided that the Plan does not have to pay for the tetanus, diphtheria toxoids and acellular 
pertussis vaccine (TDAP) (90715) provided on July 28, 2022.  
 
  Benefits for the TDAP vaccine may be available under Medicare Part D. Contact the Plan that administers Part 
D benefits for further information concerning any benefits and appeal rights.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing provided to the enrollee.
You asked the Plan to pay for this testing. You say that this testing should be covered by the Plan. The Plan denied your request. The Plan says the Medicare billing criteria were not met. Maximus overturned the Plans denial. The Plan requested a reopen and notes that 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. The sample was collected in the provider's office/outpatient facility and shipped to the laboratory. There is no documentation that the specimen was taken by the laboratory directly. In addition, next generation sequence testing (NGS) testing panel performed included testing for FANCC and BLM genes. Testing for these genes is statutorily excluded service
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 codes. In this case, this claim could not be paid as billed due to inconsistencies with the date of service provided and the statutory exclusion of the testing provided. Medicare allows coverage for this testing for recurrent, relapsed, refractory, metastatic, or advanced stage III or IV cancer. The medical records show the enrollee was suspected of having cancer, but it was not confirmed. Based on the NCD, this type of testing is only done when the patient has a confirmed cancer diagnosis. 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.
Appeal type: Lab
Decision: Unfavorable

We decided that the Plan does not have to pay for genetic testing provided to the enrollee on June 8, 2021.
You asked the Plan to pay for this testing. You say that this claim should be paid. The Plan denied your request. The Plan says the Medicare billing criteria were not met. Maximus overturned the Plans denial for medical necessity. The Plan requested a reopen and stated the issue was statutory exclusion and data errors on the claim and not medical necessity. The Plan notes that the clinical information provided does not support coverage under NCD 90.2, therefore this test is statutory excluded. The claim was billed with a place of service (POS-81) inconsistent with Medicare rules. An independent laboratory taking a sample in its laboratory shows "81" as place of service. There is no documentation that the specimen was taken by the laboratory directly.
The Plan is correct in this case. The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. In this case, the claim was not billed with an appropriate POS code and the medical records provided do not support the services billed. 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 June 8, 2021.
Appeal type: Practitioner Services
Decision: Favorable

 
We decided that the Plan has to pre-approve an epidural steroid injection (ESI) (64483). 
 
You asked the Plan to pre-approve the ESI. You say that the enrollee has attempted physical therapy services. 
You say that the enrollee had home physical therapy visits and had felt they were going well until the pain 
increased again. The Plan denied your request. The Plan says that the requested ESI is not medically necessary. 
 
The Plan follows Medicare rules. Medicare rules say that epidural steroid injection (ESI) will be considered 
medically reasonable and necessary when the three (3) requirements 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 pre-approve the ESI. Our reviewer says that the 
requested ESI is medically necessary. Our physician reviewer found the provided documentation indicates that 
the enrollee cannot tolerate physical therapy. The reviewer also found that the enrollee is not able to take 
NSAIDs. Therefore, the reviewer found that the requested ESI is medically reasonable and necessary. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the ESI have been met. Therefore, we decided that the Plan has to pre-approve 
an epidural steroid injection (ESI) (64483).  
 
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: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the implantable loop reader (ILR) (33285). 
 
You asked the Plan to pre-approve the ILR. You say that the service is necessary. The Plan denied your 
request. The Plan says given the lack of demonstrated stroke reduction (or any other clinical benefit) with the 
increased atrial fibrillation detection with long-term monitoring using an implantable loop recorder (and the 
other reasons noted), the denial of this request is upheld. 
 
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 ILR. Our physician reviewer found 
there is insufficient documentation to support the medical necessity for the service in this enrollee's 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 ILR have not been met. Therefore, we decided that the Plan does not have to 
pre-approve the implantable loop reader (ILR) (33285).
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 2 power wheelchair, with captain's seat & 
power tilt (K0835). 
 
You asked the Plan to pre-approve the power wheelchair. You say that please review the attached medical 
documentation to support the need of the custom medical equipment being requested. The Plan denied your 
request. The Plan says the enrollee does not meet the medically necessary criteria for a group 2 power 
wheelchair with captains chair. 
 
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 patients 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 the power wheelchair. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee is non-ambulatory and cannot use a cane or walker for mobility. The 
enrollee cannot functionally propel a manual wheelchair due to upper extremity weakness and impaired 
cardiorespiratory function. The enrollee cannot operate a power scooter due to requiring assistance with 
transfers and a high turning radius. The enrollee requires a power wheelchair for mobility and accomplishing 
their daily activities. However, the clinical documentation is insufficient why a lower-level power wheelchair 
would not suffice for the enrollees needs versus a group 2 power wheelchair. There is insufficient clinical 
documentation regarding the enrollees upper extremity strength and range of motion and why the enrollee 
cannot perform pressure relief; no graded muscle strength or specific range of motion is provided. The enrollee 
does not have a history of skin breakdown and it is not clear why he requires power tilt. Additionally, the 
enrollee is noted to have lower extremity edema but there is no clinical history that would support this, and the 
grading of the edema is not provided. It is not clear why the enrollee requires power elevating leg rests. 
Therefore, the group 2 power wheelchair with power tilt and power elevating leg rests 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 power wheelchair have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a group 2 power wheelchair, with captain's seat & power tilt (K0835).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 88341 billed for date of service May 25, 
2022. 
 You asked the Plan to pay for procedure code 88341. You say that the frequency of services billed is supported. 
The Plan denied your request. The Plan says the number of units billed exceeds the maximum allowed. The 
Plan has paid for 13 units of code 88341, but the 14th unit billed is not covered. 
 
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 88341 is 13. The MAI value for this code is 3. You billed 14 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 88341 have not been met. Therefore, we decided that the 
Plan does not have to pay for procedure code 88341 billed for date of service May 25, 2022.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve LTACH services. 
 
You asked the Plan to pre-approve the LTACH services. You say that the enrollee is stable to be transferred 
and any discharge plan other than LTACH would be detrimental to the enrollee's health and safety. The Plan 
denied your request. The Plan says the LTACH services you are requesting do not meet the requirements for 
approval. 
 
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 the enrollee is still somewhat unstable with recent infection and requires short-
term additional acute care that can be safely met at the current facility. Transfer to the LTACH would not be 
clinically advantageous at this time and completion of treatment at the current facility is 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 the LTACH services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve LTACH services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve ultrasound guided radiation therapy (G6001). 
 
You asked the Plan to pre-approve the service. You say that this allows you to track the progress of treatment 
and adjust the course of treatment, if necessary, which can lead to fewer side effects and a better outcome. The 
Plan denied your request. The Plan says the requested service is not covered by Medicare or the Health Plan 
 
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 service. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found to bill for daily simple simulations (77280- also requested in this case) and/or image guided 
radiation therapy (IGRT) for a technology for which need has not been established by published data or 
supported by consensus guidelines (many of which recommend against treatment with these devices in general- 
citations below) is not necessary. Billing for daily IGRT or daily simulations (also requested in this case) which 
would not be furnished in accordance with accepted standards of medical practice. 
 
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 service have not been met. Therefore, we decided that the Plan does not 
have to pre-approve ultrasound guided radiation therapy (G6001).
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Keytruda with cyclophosphamide and docetaxel. 
 
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. The rules say that Medicare pays for a drug or biological only if it is safe 
and effective and otherwise reasonable and 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 these services. Our reviewer says that 
the services are not medically necessary. Our physician reviewer found the combination of docetaxel, 
cyclophosphamide, and pembrolizumab for the neoadjuvant treatment of triple negative breast cancer is not a 
standard regimen. It is not Food and Drug Administration (FDA)-approved or supported by the National 
Comprehensive Cancer Network (NCCN) guidelines. There is also no clear rationale why the enrollee cannot 
receive the standard regimen for her high risk disease. The requested drugs are 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 Keytruda with cyclophosphamide and docetaxel.