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

 
We decided that the Plan has to pre-approve acute inpatient rehabilitation facility (IRF) admission and services. 
 
You asked the Plan to pre-approve IRF care. You say that the inpatient rehabilitation facility services are 
medically necessary. The Plan denied your request. The Plan says the inpatient rehabilitation facility services 
are not medically necessary. 
 
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 the enrollee's medical record overall significantly complies with the various documentation requirements 
for IRF admission, as best summarized by the notes from 10/19/23. The enrollee's condition is in fact complex 
and fragile and, barring any new evidence to the contrary, there is every reason to expect that they will be able 
to participate in and benefit from inpatient rehabilitation facility services. The requested inpatient rehabilitation 
facility admission is approved. 
 
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: Transportation
Decision: Unfavorable

 
We decided that the Plan does not have to pay for air ambulance services received on January 1, 2023. 
 
You asked the Plan to pay for the air ambulance services. You say that the services were a medical emergency, 
and you were on a cruise ship at the time of services. The Plan denied your request. The Plan says the services 
were not medically necessary. 
 The Plan follows Medicare rules. The rules say that Medicare pays for air ambulance services only if your 
medical condition is such that transportation by ground ambulance is not appropriate.  
 
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 air ambulance services. Our reviewer 
says that the air ambulance services were not medically necessary. Our physician reviewer found based on the 
medical records provided the documentation supports that you suffered from an illness that contraindicated 
transportation by any means other than ambulance. Transport from Colombia, South America to Florida was 
not feasible by ground. Provided medical records in this case do not document the transferring hospital did not 
have adequate facilities to provide the medical services needed. The records document the transport was 
initiated at the request of the family. The Medicare criteria for coverage is not met. 
 
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 air ambulance services have not been met. Therefore, we decided that the 
Plan does not have to pay for air ambulance services received on January 1, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a battery backup (E1399). 
 
You asked the Plan to pre-approve the battery backup. You say that this item is medically necessary. The Plan 
denied your request. The Plan says this is not a covered item. 
 
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 a battery backup (E1399).
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the urinary tract infection (UTI) pathogen panel (87801, 
87150, 87500, 87651 and 81002) provided on November 7, 2022. 
 
You asked the Plan to pay for the UTI pathogen panel. You say that this test was necessary and is supported in 
the medical record. The Plan denied your request. The Plan says this test is not considered standard of care and 
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 pay for the UTI pathogen panel. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found the degree of testing provided in this case was 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 UTI pathogen panel have not been met. Therefore, we decided that the Plan 
does not have to pay for the urinary tract infection (UTI) pathogen panel (87801, 87150, 87500, 87651 and 
81002) provided on November 7, 2022.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve home-based pulmonary rehabilitation services (codes 
94625, 98961, 98962, 98966, 98967, 98968, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99453, 
99454, 99457, and 99458). 
 
You asked the Plan to pre-approve home-based pulmonary rehabilitation services. You say that you believe the 
Plan's rationale for the denial is not consistent with Medicare rules. You also say that your home-based 
pulmonary rehabilitation program meets all current requirements for coverage under Medicare. The Plan 
denied your request. The Plan says the enrollee does not meet the medical necessity criteria for the requested 
virtual pulmonary rehabilitation services. 
 
The Plan follows Medicare rules. Medicare rules say that services must be provided only in the following place 
of service (POS): 11 (physicians office), 19 (Off-Campus Outpatient Hospital or 22 (On-Campus Outpatient 
Hospital). Medicare rules also say that all settings must have a physician immediately available and accessible 
for medical consultations and emergencies at all times when program services are being furnished. 
 
 
 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 home-based pulmonary rehabilitation 
services. Our reviewer says that the criteria for coverage have not been met. Our physician reviewer found a 
home-based pulmonary rehabilitation program with services provided via telehealth does not meet the criteria 
described in the LCA regarding the location of care or the immediate availability of a physician.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of home-based pulmonary rehabilitation services have not been met. Therefore, we 
decided that the Plan does not have to pre-approve home-based pulmonary rehabilitation services (codes 
94625, 98961, 98962, 98966, 98967, 98968, 99202, 99203, 99204, 99205, 99212, 99213, 99214, 99215, 99453, 
99454, 99457, and 99458).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve transcatheter mitral valve repair with imaging guidance. 
 
You asked the Plan to pre-approve transcatheter mitral valve repair. You say that you are severely short of 
breath and it is urgent to address this issue. The Plan denied your request. The Plan says the record does not 
show a face-to-face visit with a cardiothoracic surgeon. 
 
The Plan follows Medicare rules. Medicare rules state that transcatheter edge-to-edge repair of the mitral valve 
may be covered through Coverage with Evidence Development (CED) if certain criteria are met.  
We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve transcatheter mitral valve repair. Our 
reviewer says that you do not meet criteria for this surgery. Our physician reviewer found the agreement of the 
cardiothoracic surgeon as a member of your heart team is an integral part of your candidacy evaluation and 
needs to be obtained before you undergo this procedure. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of transcatheter mitral valve repair have not been met. Therefore, we decided that 
the Plan does not have to pre-approve transcatheter mitral valve repair with imaging guidance.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a group 3 standard power wheelchair with multiple 
power options (K0861) and additional items and accessories (codes E1007, E1012, E2311, E2313, E2361, 
E2377, and E2603). 
 
You asked the Plan to pre-approve a group 3 standard power wheelchair and additional items and accessories. 
You say that the enrollee has multiple medical conditions that have resulted in her profoundly limited mobility. 
Without the requested chair with its power functions, the enrollee will not be able to perform mobility related 
activities of daily living (MRADLs) independently or perform the needed pressure relief to prevent skin 
breakdown. The Plan denied your request. The Plan says the enrollee does not have a qualifying diagnosis 
causing mobility limitation for which a group 3 power wheelchair is medically needed. 
 
The Plan follows Medicare rules. Medicare rules say that a Group 3 power wheelchair (PWC) with multiple 
power options (such as code K0861) is covered if the criteria listed in the Medicare rules section of this letter 
are met. Medicare rules also say that if the PWC base is not covered, then related accessories will be denied. 
 
 
  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 group 3 standard power wheelchair 
and additional items and accessories. Our reviewer says that the enrollee does not meet the criteria for 
coverage. Our physician reviewer found the enrollee requires a power wheelchair for mobility and 
accomplishing their daily activities. However, the clinical documentation is insufficient as to why a lower-level 
power wheelchair would not suffice for their needs versus a Group 3 power wheelchair. Our reviewer found 
that there is inadequate clinical documentation regarding why the enrollee requires power tilt and recline and 
cannot perform pressure relief. Our physician reviewer also found that the enrollee has no history of skin 
breakdown and is noted to have 3 out of 5 motor strength. Group 3 power wheelchairs are typically indicated 
for patients with total paralysis or neurological disorders such as with spinal cord injury or multiple sclerosis. 
 
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 group 3 standard power wheelchair and additional items and accessories have 
not been met. Therefore, we decided that the Plan does not have to pre-approve a group 3 standard power 
wheelchair with multiple power options (K0861) and additional items and accessories (codes E1007, E1012, 
E2311, E2313, E2361, E2377, and E2603).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for hospital outpatient clinic services provided on May 18, 2023, 
to July 03, 2023. 
 
You asked the Plan to pay for hospital outpatient clinic services. You say that you are requesting 
reconsideration for the denied claim. The Plan denied your request. The Plan says that unauthorized, out-of-
network care is not covered. 
 
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 provider of the item(s)/service(s) at issue in this appeal is not a network provider with the Plan. The Plan 
did not pre-approve the item(s)/service(s) at issue. We found no exception that would require the Plan to pay for the item(s)/service(s). Therefore, we decided that the Plan does not have to pay for hospital outpatient clinic 
services provided on May 18, 2023, to July 03, 2023.
Appeal type: Testing
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Functional Evaluation Testing (97750) provided on 
February 23, 2023. 
 
You asked the Plan to pay for the Functional Evaluation Testing. You say that this test was ordered based on 
medical necessity, and you would like this claim to be reprocessed for payment. The Plan denied your request. 
The Plan says the clinical value and effectiveness of Functional Evaluation Testing in the setting of cervical 
and lumbar pain have not been demonstrated in the peer-reviewed literature. 
 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 Functional Evaluation Testing. Our 
reviewer says that the requested items/services are not considered medically reasonable and necessary in this 
case. Our physician reviewer found the provided medical records and review of the current peer-reviewed 
medical literature do not document that use of Functional Evaluation Testing (97750) has been shown in 
controlled studies in a Centers for Medicare & Medicaid Services (CMS) approved journal to result in long 
term health benefits in patients with a diagnosis of cervical and lumbar pain. Our reviewer also found in 
addition, there are no provided medical records from the referring physician in this case documenting necessity 
of the Functional Evaluation Testing. 
 
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 Functional Evaluation Testing have not been met. Therefore, we decided 
that the Plan does not have to pay for the Functional Evaluation Testing (97750) provided on February 23, 
2023.
Appeal type: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Botox to be provided by an out-of-network (OON) 
provider.  
 
You asked the Plan to pre-approve OON services. The Plan denied your request. The Plan says the services are 
available in-network. 
 
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 services at issue in this appeal. We found no exception that would require the 
Plan to pre-approve these OON services. Therefore, we decided that the Plan does not have to pre-approve 
Botox to be provided by an out-of-network (OON) provider.
Appeal type: Outpatient Therapies
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve 15 additional Physical Therapy visits. 
 
You asked the Plan to pre-approve the therapy services. You say that PT is medically necessary for the 
enrollee. The Plan denied your request. The Plan says the enrollee is stable to continue rehabilitation with the 
home exercise program and follow-up with their physician... 
 
The Plan must follow Medicare rules. The rules say that Medicare pays for medically necessary outpatient 
therapy. 
 We asked our physician reviewer to carefully review the case file and apply the relevant Medicare rules to 
determine if the Plan was correct in denying the request to pre-approve the therapy services. Our reviewer says 
that skilled services are not necessary to restore or maintain function or to prevent deterioration of the enrollee's 
condition. Our physician reviewer found the enrollee has responded to the plan of care and is able to perform a 
home exercise program. His condition does not require continued input from a skilled therapist.  
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of the therapy services have not been met. Therefore, we decided that the Plan 
does not have to pre-approve 15 additional Physical Therapy visits.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genicular artery embolization of knee. 
 
You asked the Plan to pre-approve genicular artery embolization of knee. You say that this procedure is 
medically necessary for the patient's condition and will provide long lasting pain relief that will improve their 
quality of life. 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 genicular artery embolization of knee. 
Our reviewer says that the requested items/services are not considered medically reasonable and necessary in 
this case. Our physician reviewer found there is limited literature that shows this to be an effective or safe 
treatment for the noted pathology. While the studies are promising, further research is needed to corroborate 
that genicular artery embolization is as good or better than standard treatments for knee osteoarthritis. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of genicular artery embolization of knee have not been met. Therefore, we decided 
that the Plan does not have to pre-approve genicular artery embolization of knee.
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to provide coverage for the Intracept procedure for the enrollee.
You asked the Plan to provide coverage for this request. The Plan denied your request. The Plan says this
device and procedure are not covered by Medicare. Maximus overturned the Plans request. The Plan requested
a reopen and stated that Maximus did not apply the correct coverage criteria.
Our Medical Director looked at the case file and the reopen request. At issue is coverage for the Intracept
procedure (intraosseous basivertebral nerve ablation). The records show the enrollee is a 47-year-old woman
with chronic low back pain that has been treated with multiple medications, home exercises, physical therapy,
lumber epidural steroid injections, and radiofrequency ablation. In addition, the enrollee has cervical disc
disorder with radiculopathy. An MRI of the lumbar spine showed bilateral facet joint arthrosis at L3-L4 and
L4-L5, as well as a broad-based left foraminal zone disc protrusion and neural foraminal narrowing. The Plan
is correct in this case. The enrollee has multiple potential causes of back pain, and her MRI report does not
document Modic I or II changes of the lumbar spine.
One double-blind randomized study has shown that improvement with the Intracept procedure was not
clinically significant when compared with a sham procedure. Additional studies suggest that the Intracept
procedure may be more effective for low back pain than conservative treatment. Limitations of the published
medical literature include a limited number of studies, industry funding of the studies, and a high risk of bias
from lack of controls. Additional study is needed to validate any benefit of the procedure, and to compare it to
other interventions. Current medical literature indicates that the Intracept procedure is investigational 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 this request have not been met. Therefore, we decided that the Plan does not
have to provide coverage for the Intracept procedure for the enrollee.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a Minuteman device. 
 
You asked the Plan to pre-approve a Minuteman device. You say that the services are necessary. The Plan 
denied your request. The Plan says medical necessity has not been established. Therefore, coverage criteria 
have not been met. 
 
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 a Minuteman device. Our reviewer says 
that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found no compelling rationale is presented or extenuating circumstances noted to support 
the medical necessity of this request as an exception. Therefore, the requested Minuteman Device 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 a Minuteman device have not been met. Therefore, we decided that the Plan 
does not have to pre-approve a Minuteman device.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for lab testing billed with code 0012M for date of service May 
19, 2023. 
 
You asked the Plan to pay for the lab testing. You say that you believe this testing is medically necessary and 
covered. The Plan denied your request. The Plan says this testing is not covered by Medicare. The Plan must 
follow Medicare rules. Medicare rules say that lab testing billed with code 0012M remains non-covered.  The 
lab services in dispute were billed with code 0012M. We looked at the file and Medicare rules. Therefore, we 
decided that the Plan does not have to pay for lab testing billed with code 0012M for date of service May 19, 
2023.