Persius/hicric huggingface dataset:
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 BiPAP capability is extremely limited. The Plan 
denied your request. The Plan says a BiPAP would meet the enrollee's needs.  
 
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 physician reviewer 
found that the enrollee has chronic hypoxemic respiratory failure from chronic obstructive pulmonary disease. The record indicates that the enrollee was successfully treated with BiPAP in the hospital in 2021. The 
provided documentation does not contain sufficient detailed information to justify the treatment selected. The 
enrollee could be treated with a BiPAP machine with advanced volume-assured pressure support (AVAPS) 
capability and failure of such a device has not been documented. The elements of the coverage criteria are not 
satisfied. The requested service cannot be recommended. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of a ventilator have not been met. Therefore, we decided that the Plan does not 
have to pre-approve a ventilator.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve medical nutrition therapy services (codes 97802 and 
97803). 
 
You asked the Plan to pre-approve medical nutrition therapy services. You say that you need to see a 
nutritionist because your blood pressure is always high, and your sugar goes up and down. You also say that 
you are a diabetic and hypertensive, and you have to lose weight ordered by your primary physician. The Plan 
denied your request. The Plan says the medical information received from your primary care physician does not 
indicate that you have a diagnosis of renal (kidney) disease or diabetes. The Plan also says that based on the 
medical information provided you do not meet the Medicare criteria for medical nutritional therapy. 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medical nutrition therapy services 
only for enrollees with renal disease or diabetes.  
 
The submitted records do not show that you suffer from renal disease or diabetes. Therefore, we decided that 
the Plan does not have to pre-approve medical nutrition therapy services (codes 97802 and 97803).
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 admission to IRF is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the enrollee does not meet the Medicare criteria for 
admission to an IRF. The services the enrollee needs can be provided safely in other settings, for example, a 
skilled nursing facility (SNF). 
 
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 there are no complex nursing or rehabilitation needs. While the enrollee has a need 
for physical or occupational therapy, there is no documentation of a need for an intensive rehabilitation 
program. 
 
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 the addition to an approved prosthesis for an alignable 
system (L5910). 
 
You asked the Plan to pre-approve the prosthetic addition L5910. You say that the requested items should be 
approved. The Plan denied your request. The Plan says code L5910 cannot be approved as it is not compatible 
with the base code L5540. Since the base code is for a non-alignable system, the alignable system code is not 
appropriate. 
 
Please note: Maximus reviewed the Plans denial rationale and finds that it is not appropriate. All prosthesis 
base codes are for non-alignable systems and inclusion of code L5910 is to denote an alignable system. As 
such, we based our decision on medical necessity of the addition. 
 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 prosthetic addition L5910. Our 
reviewer says that the requested item (L5910) is not considered medically reasonable and necessary in this 
case. Our physician reviewer found the enrollee is a 61-year-old man who previously underwent a right below 
knee amputation. On March 15, 2023, it is documented that the enrollee was progressing as expected. A 
Prosthesis Amendment notes that the enrollee will be able to ambulate as a functional level to limited 
community ambulator with the below knee prosthesis. The clinical information available in the case file does 
not support that an alignable system is medically reasonable and necessary for the enrollee 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 the prosthetic addition L5910 have not been met. Therefore, we decided that the 
Plan does not have to pre-approve the addition to an approved prosthesis for an alignable system (L5910).
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve acute inpatient rehabilitation facility (IRF) admission 
and services. 
 
You asked the Plan to pre-approve IRF care. You say that the enrollee needs to go into rehabilitation to 
improve health. The Plan denied your request. The Plan says that there is no need for an intensive rehabilitation 
program. 
 
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 the enrollee's nursing, medical, and rehabilitation needs does 
not require an acute hospital inpatient stay with an interdisciplinary approach to rehabilitation care. The 
enrollee does not require treatment by multiple therapies, including either physical therapy or occupational 
therapy, and an intensive rehabilitation therapy program. Medically necessary care can be provided in a 
different level of care. There is not a reasonable expectation that this enrollee will be able to fully participate in 
 and benefit from  the intensive rehabilitation therapy program provided in an IRF. 
 
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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a percutaneous image-guided lumbar decompression 
(PILD (0275T). 
 
You asked the Plan to pre-approve the surgical procedure. You say that the requested procedure is medically 
necessary for the enrollee. The Plan denied your request. The Plan says the request does not show you are part 
of a clinical study. 
 The Plan must follow Medicare rules. Medicare rules say that Medicare will cover PILD under CED for 
beneficiaries with LSS who are enrolled in a CMS-approved prospective longitudinal study PILD procedure 
using and FDA-approved/cleared device that completed a CMS-approved RCT that met the criteria listed in the 
January 2014 NCD.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the surgical procedure have not been met. Therefore, we decided that the Plan does not have to pre-
approve a percutaneous image-guided lumbar decompression (PILD (0275T).
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 requesting an expedited appeal 
for the denial of an LTACH admission. The Plan denied your request. The Plan says the enrollee does not meet 
the guidelines for care in an LTACH.  
 
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 improving but is still somewhat unstable and requires 
additional acute care services that can safely be provided at the current facility until more stable and 
appropriate for transfer. There are no services at the LTACH that the enrollee requires that are not already 
available and covered at the current facility. Transfer to the LTACH would not be clinically advantageous 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 long term acute care hospital (LTACH) services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the thyroid stimulating hormone (TSH) (84443) provided 
February 9, 2023. 
 
You asked the Plan to pay for the laboratory service. You say that please reconsider these lab charges for 
payment with medical records attached for this date of service. The Plan denied your request. The Plan says 
this service is not covered per Medicare NCD. 
 
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 laboratory service. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the enrollee with a history of myotonic dystrophy type 2 (DM2) with chronic kidney 
disease stage 3, history of colon polyps, hyperlipidemia, hypertension, anemia and vitamin D deficiency who 
presented to surgeon's office for consult for colonoscopy. There was no specific clinical rational for a TSH. The 
enrollee has no history of thyroid disease. The review has determined that the items/services at issue in this 
case were 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 laboratory service have not been met. Therefore, we decided that the Plan 
does not have to pay for the thyroid stimulating hormone (TSH) (84443) provided February 9, 2023.
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's admission to an LTACH is 
medically necessary. The Plan denied your request. The Plan says the enrollee is currently unstable for transfer 
to an LTACH. Continued stay at acute hospital until the enrollee is stable enough for discharge to a lower level 
of care has not been denied. 
 
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 is receiving appropriate care at the present acute care hospital. The 
enrollee does not require services at the LTACH that are not available at the acute care hospital where the 
enrollee is currently receiving 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 LTACH services.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve continuous positive airway pressure (CPAP) supplies. You asked the Plan to pre-approve the requested supplies. You say that the supplies are part of your everyday 
routine. The Plan denied your request. The Plan says the coverage criteria are not met. 
 
The Plan must follow Medicare rules. Medicare rules say that PAP devices and related supplies are only 
covered under certain medical indications.  
 
We looked at the file and Medicare rules. In this case, there are insufficient records to show that coverage 
criteria have been met. There is no documentation of a clinical evaluation. The records that were provided do 
not show evidence of adherence for usage. Based on this information, we decided that Medicare rules for 
coverage of the requested supplies have not been met. Therefore, we decided that the Plan does not have to pre-
approve continuous positive airway pressure (CPAP) supplies.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab services provided on October 25, 2022, by an out-of-
network (OON) provider.  
 
You asked the Plan to pay for the lab services. You say that these services were medically necessary and are 
covered by Medicare. The Plan denied your request. The Plan says these services were neither provided nor 
ordered by a network provider. 
 
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 pay for care from out-of-network providers only in cases involving emergencies, 
out of area urgent care and pre-approved care. 
 The requested provider in this case is not a network provider with the Plan. These services were not ordered by 
a network provider. The Plan did not pre-approve the item/service at issue. We found no exception that would 
require the Plan to pay for these items/services. Therefore, we decided that the Plan does not have to pay for 
lab services provided on October 25, 2022, by an out-of-network (OON) provider.
Appeal type: Imaging
Decision: Favorable

 
We decided that the Plan has to pre-approve an MRI of the lumbar spine. 
 
You asked the Plan to pre-approve an MRI of the lumbar spine. You say that an updated MRI is necessary to 
determine the next step in the enrollee's treatment. The Plan denied your request. The Plan says that an MRI of 
the lumbar spine is not medically necessary. 
 
The Plan must follow Medicare rules. Medicare rules say that MRIs 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 an MRI of the lumbar spine. Our 
reviewer says that an MRI of the lumbar spine is medically necessary. Our physician reviewer found that the 
enrollee has had epidural steroid injections. However, during their physical therapy encounter on May 5, 2023, 
it revealed absent reflexes of the left lower extremity. Therefore, with the historical findings and the absent of 
the left leg reflexes the enrollee qualifies to receive an MRI of the lumbar spine without repeating an 
unsuccessful course of physical therapy. 
 
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 MRI of the lumbar spine have been met. Therefore, we decided that the Plan 
has to pre-approve an MRI of the lumbar spine.  
 
If the Plan does not agree with our decision, they can ask us to open a case again. We only open a case again 
if we believe there was a mistake or if there is new information to review. The Plan has to show us the mistake 
and/or send us the new information. This does not happen often. If we decide to open the case again, we will 
send you a letter.
Appeal type: Inpatient Hospital
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an IRF admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that you need this level of care to get the rehabilitation 
you need to get strong and be able to care for yourself. The Plan denied your request. The Plan says the IRF 
services requested do not meet the requirements for approval.  
 
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 do not 
require treatment by multiple therapies, including either physical therapy or occupational therapy, and an 
intensive rehabilitation therapy program. While you may have a need for physical therapy 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 you will be able to fully 
participate in and benefit from the intensive rehabilitation therapy program provided in an IRF. 
 
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 an IRF admission and services.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an office visit and related supplies to be provided by an 
out-of-network (OON) provider.  
 
You asked the Plan to pre-approve an office visit and related supplies. You say that the services should be 
covered. The Plan denied your request. The Plan says this was not authorized. 
 
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 
an office visit and related supplies 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 procedure code 99100 billed for date of service July 11, 
2022. 
 
You asked the Plan to pay for procedure code 99100. You say that you have submitted medical records to 
support payment. The Plan denied your request. The Plan says procedure code 99100 is considered bundled 
and not separately payable.  
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate procedure code. 
 
We find that procedure code 99100 has a status indicator of B on the Physician Fee Schedule. This means that 
procedure code 99100 is not separately payable. Based on this information, we decided that Medicare rules for 
coverage of procedure code 99100 have not been met. Therefore, we decided that the Plan does not have to pay 
for procedure code 99100 billed for date of service July 11, 2022.