Persius/hicric huggingface dataset:
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve implantation of a CardioMEMS hear failure system 
implant device (33289). 
 
You asked the Plan to pre-approve CardioMEMS device. You say that it is your recommendation that the 
enrollee urgently needs this device and procedure due to worsening heart failure. The Plan denied your request. 
The Plan says the CardioMEMS device is experimental and investigational as it continues to be evaluated in 
clinical trials for utility, safety, effectiveness, and long-term outcome. 
 
The Plan must follow Medicare rules. Medicare rules say that items and services that are not medically 
necessary are not covered.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of CardioMEMS device have not been met. Therefore, we decided that the Plan does not have to pre-
approve implantation of a CardioMEMS hear failure system implant device (33289).
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve maxillary and mandibular surgery for tori removal. 
 
You asked the Plan to pre-approve the tori removal. You say that you do not know why this is being denied, 
since it is being done at a hospital, and it is something that an oral surgeon has to do. The Plan denied your 
request. The Plan says tori removal is not listed as a covered benefit. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plans coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve 
maxillary and mandibular surgery for tori removal.
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 need inpatient rehabilitation in order to continue 
to build strength/endurance to be able to return back to prior level of functioning. The Plan denied your request. 
The Plan says your records do not show that you need an intensive team for your care. Services needed 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 your 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: Drugs
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve Fulphila. 
 
You asked the Plan to pre-approve Fulphila. You say that the claim should be reprocessed. The Plan denied 
your request. The Plan says they are not required to pre-approve services associated with a clinical trial are the 
responsibility of the original Medicare contractor.  
 
The Plan must follow Medicare rules. Medicare rules say that Medicare contractors will pay for covered 
clinical trial services furnished to beneficiaries enrolled in managed care plans.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of Fulphila have not been met. Specifically, the Plan is not required to pre-approve services related to 
a clinical trial since they are not required to pay for clinical trial services. Therefore, we decided that the Plan 
does not have to pre-approve Fulphila.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the expandable controller (E2377) harness (E2313) and 
electronic connection (E2311). 
 
You asked the Plan to pre-approve the upgraded electronics. You say that based on these records, the enrollee's 
diagnosis is consistent with the need for Group 3 power wheelchair with multiple power seating options. The 
Plan denied your request. The Plan says the upgraded electronics 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 the upgraded electronics. 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 independent with upper body activities of daily living. The enrollee 
has adequate strength to manage standard power drive controls. The upgraded electronics are not medically 
necessary to meet the enrollee's needs. 
 
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. Therefore, we decided that the Plan 
does not have to pre-approve the expandable controller (E2377) harness (E2313) and electronic connection 
(E2311).
Appeal type: Surgery
Decision: Unfavorable

We decided that the Plan does not have to pre-approve a bunionectomy to be provided by an out-of-network (OON) provider.
You asked the Plan to pre-approve a bunionectomy. You say that the Plan does not have a provider for this procedure. The Plan denied your request. The Plan says that network providers are available to continue necessary care. Maximus overturned the Plan's denial. The Plan requested a reopening and provided the 2022 Evidence of Coverage.
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 a bunionectomy to be provided by an out-of-network (OON) provider.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for laboratory services identified with codes 87631 and 99072 
for date of service November 29, 2022. 
 
You asked the Plan to pay for laboratory services identified with codes 87631 and 99072. You say that you 
disagree with the Plan's denial. The Plan denied your request. The Plan says the claim for this molecular 
pathology testing did not include the required unique identifier. 
 
The Plan must follow Medicare rules. The rules say that for molecular diagnostic tests, such as the test at issue, 
the MolDX program requires these tests to be reviewed to determine whether Medicare reasonable and 
necessary requirements are met. When such review is complete, the test is assigned a unique identifier and the 
coverage status is listed in the DEXTM Diagnostics Exchange. 
 
We looked at the file and Medicare rules. Review of the claim does not show that the required unique identifier 
was reported. We find that procedure code 99072 has a status indicator of B on the Physician Fee Schedule. 
This means that procedure code 99072 is not separately payable. Based on this information, we decided that 
Medicare rules for coverage of laboratory services identified with codes 87631 and 99072 have not been met. 
Therefore, we decided that the Plan does not have to pay for laboratory services identified with codes 87631 
and 99072 for date of service November 29, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve an expandable controller (E2377), a harness (E2313), an 
electronic connection between wheelchair controller and two or more power seating system motors (E2311) 
and 2" adapter plate-pelvic/thigh adapter (K0108x2). 
 
You asked the Plan to pre-approve wheelchair accessories. You say that you disagree with the denial because 
the accessories are medically necessary. The Plan denied your request. The Plan says the requested accessories 
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 wheelchair accessories. Our reviewer 
says that the requested items/services are not considered medically reasonable and necessary in this case. Our 
physician reviewer found that according to Medicare, a power mobility device is medically necessary if an 
enrollee has a mobility limitation that significantly impairs her ability to participate in one or more mobility-
related activities of daily living. The mobility limitation cannot be sufficiently and safely resolved using a fitted 
cane or walker, or the enrollee does not have sufficient upper extremity function to self-propel an optimally 
configured manual wheelchair. Additionally, if any POV or PWC is only for use outside the home, it is denied 
as noncovered. The enrollee must also have the mental and physical capabilities to safely operate the power 
wheelchair and the home provides adequate access between rooms, maneuvering space, and surfaces for the 
operation of the PWC. An expandable controller is an electronic system that is capable of accommodating one 
or more additional features and can operate 3 or more powered seating options. The requested electrical 
accessories are not medically necessary as the enrollee does have use of the upper extremity and can operate 
and control the power options using the switches that are included in the basic 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 wheelchair accessories have not been met. Therefore, we decided that the Plan 
does not have to pre-approve an expandable controller (E2377), a harness (E2313), an electronic connection 
between wheelchair controller and two or more power seating system motors (E2311) and 2" adapter plate-
pelvic/thigh adapter (K0108x2).
Appeal type: Inpatient Hospital
Decision: Unfavorable

We decided that the Plan does not have to pay for inpatient hospital services provided from August 1, 2021, to August 14, 2021, at the Diagnosis Related Group (DRG) originally billed.
You asked the Plan to pay for the inpatient hospital services at the DRG originally billed. You say that the medical records clearly support the clinical diagnosis and DRG assignment as billed. The Plan denied your request. The Plan says that the sepsis diagnosis has been removed which downgraded the DRG from 854 to 580.
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. Providers must report inpatient hospital services with the appropriate DRG, which is based, in part, on the reported principal and secondary diagnosis codes. Our Medical director looked at the case file and the reopen request. In this case, you billed the inpatient services provided with principal diagnosis code, A41.9, defined as Sepsis, unspecified organism. Our Medical Director states that the documentation in the case file does not sufficiently support the principal diagnosis code of A41.9 (Sepsis, unspecified organism). The downgrade of DRG 854 (Infectious and parasitic disease with O.R. procedure with Complication or Comorbidity) was appropriate in this case. Our Medical Director found that the enrollee's condition did not meet Medicare criteria for the inpatient hospital services provided from August 1, 2021, to August 14, 2021, at the DRG originally billed. We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided the medical records do not substantiate the DRG as billed. Therefore, we decided that the Plan does not have to pay for inpatient hospital services provided from August 1, 2021, to August 14, 2021, at the Diagnosis Related Group (DRG) originally billed.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for code 99222 billed for date of service August 5, 2022. 
 
You asked the Plan to pay for code 99222. You say that the medical records support payment of this code. The 
Plan denied your request. The Plan says code 99222 is not supported by the medical record. The records don't 
support a comprehensive evaluation. 
 
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 99222 is Initial hospital inpatient care, per day, for the evaluation and management of a patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making 
 
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 code 99222. Our reviewer says that code 99222 is not 
supported by the medical record. Our reviewer found he examination documented in the record is detailed, not 
comprehensive. There is a more appropriate code for this level of service.  

We looked at this coder's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of code 99222 have not been met. Therefore, we decided that the Plan does not 
have to pay for code 99222 billed for date of service August 5, 2022.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve the pontics (D6245 x 2). 
 
You asked the Plan to pre-approve the dental services. You say that these procedures are necessary and 
recommended by your provider. The Plan denied your request. The Plan says this service is not a covered 
benefit under your dental plan. 
 
Medicare generally does not cover dental services. However, the Plan offers a dental benefit that exceeds 
Medicare coverage. For that reason, the Plan's coverage rules apply in this case. 
 
Though the Plan offers a dental benefit in excess of Medicare coverage, the requested items or services are not 
among those covered under this benefit. Therefore, we decided that the Plan does not have to pre-approve the 
pontics (D6245 x 2).
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for procedure code 95999-26 billed for date of service May 23, 
2022. 
 
You asked the Plan to pay for the billed services. You say that the code is used to describe train of four testing. 
The Plan denied your request. The Plan says the rules for payment have not been met. 
 
The Plan must follow Medicare rules. Medicare rules say that providers must report services correctly. 
Providers must report services with the appropriate CPT code. 
 
We find that CPT code 95999 is not payable when billed with modifier 26. Based on this information, we 
decided that Medicare rules for coverage of the billed services have not been met. Therefore, we decided that 
the Plan does not have to pay for procedure code 95999-26 billed for date of service May 23, 2022.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a continuous passive motion exercise device for use 
other than knee (E0396). 
 
You asked the Plan to pre-approve a continuous passive motion exercise device. You say that your doctor 
advised that you needed the continuous passive motion exercise device to work your arm prior to surgery. The 
Plan denied your request. The Plan says a continuous passive motion exercise device for your shoulder is not a 
covered benefit. 
 
The Plan must follow Medicare rules. The rules say that CPM devices are covered only for patients who have 
received total knee replacement surgery. 
 
You have not had total knee replacement surgery. Therefore, we decided that the Plan does not have to pre-
approve a continuous passive motion exercise device for use other than knee (E0396).
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 is ready to transfer once an IRF 
admission is approved. The Plan denied your request. The Plan says the enrollee does not meet the Medicare 
criteria for an IRF admission. 
 
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 enrollee does not require treatment by multiple therapies, including either 
physical therapy or occupational therapy, and an intensive rehabilitation therapy program. While the medical 
record supports a need for physical or occupational therapy, there is no documented need for intensive 
rehabilitation services. 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. 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 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 were independent before the hospitalization and 
want to return to being independent. The Plan denied your request. The Plan says the services you need can be 
provided safely in another setting such as a skilled nursing facility, home with home health services or home 
with outpatient therapy.  
 
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 you do not require treatment by multiple therapies. While the medical record 
supports a need for physical 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 inpatient rehabilitation facility (IRF) admission and services.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the Cxbladder detect test (0012M) provided on November 
15, 2022. 
 
You asked the Plan to pay for the Cxbladder detect test. You say that this testing was medically necessary.  The 
Plan denied your request. The Plan says this service is not covered. 
 
The Plan must follow Medicare rules. Medicare rules say that codes 0012M and 0013M for CxBladder are non-
covered. 
 
We looked at the file and Medicare rules. The service at issue is non-covered. Based on this information, we 
decided that Medicare rules for coverage of the Cxbladder detect test have not been met. Therefore, we decided 
that the Plan does not have to pay for the Cxbladder detect test (0012M) provided on November 15, 2022.
Appeal type: Lab
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve genetic testing (81479). 
 
You asked the Plan to pre-approve genetic testing. You say that it is medically necessary to do this testing and 
it should be paid for. The Plan denied your request. The Plan says the requested testing is considered excluded 
from coverage by Medicare. 
 
The Plan must follow Medicare rules. Medicare rules say that current genetic testing methods are unable to 
detect mutations in all individuals with suspected mitochondrial disease, and there is no proven effective 
treatment for persons with a known mitochondrial disease. 
 
We looked at the file and Medicare rules. According to LCA A55291, mitochondrial nuclear gene tests do not 
support the required clinical utility for the established Medicare benefit category and are statutorily excluded 
tests. Based on this information, we decided that Medicare rules for coverage of genetic testing have not been 
met. Therefore, we decided that the Plan does not have to pre-approve genetic testing (81479).