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

We decided that the Plan does not have to pay for the drug testing provided to the enrollee on March 17, 2022.

You asked the Plan to pay for the drug testing. You say that you disagree with the Plan's denial. The Plan
denied your request. The Plan says that the services provided are not payable. Maximus overturned the Plan's
denial because there was no rationale provided. The Plan requested a reopening and stated that these services
cannot be confirmed. The Plan is correct in this case. Medicare rules say that the provider, supplier, or
beneficiary, as appropriate, must furnish to the intermediary or carrier sufficient information to determine
whether payment is due and the amount of payment. You have not provided results for the testing in question.
Without results we cannot confirm testing occurred on this date of service. Based on this information, we
decided that there is insufficient information in the record to determine if Medicare rules for coverage of the
drug testing have been met. Therefore, we decided that the Plan does not have to pay for the drug testing
provided to the enrollee on March 17, 2022.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve arthrodesis (22614). 
 
You asked the Plan to pre-approve arthrodesis. You say that this is medically necessary. The Plan denied your 
request. The Plan says this is not medically necessary for the enrollee's medical condition. 
 
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 arthrodesis. Our reviewer says that the 
requested items/services are not considered medically reasonable and necessary in this case. Our physician 
reviewer found detailed documentation regarding a trial and failure of recent, reasonable, comprehensive, less 
invasive conservative care measures is not evident. There is no clear documentation of medications having 
been tried and failed, no injections having been tried and failed, and the physical therapy sessions were not 
clearly documented to be recent. Additionally, the most recent exam was from April 7, 2023, and included no 
objective findings of the lumbar spine. Moreover, recent dynamic flexion/extension films are not provided in 
order to potentially assess the amount of movement (instability) at the requested surgical levels. Detailed 
documentation is not evident regarding potential impending/inevitable temporary intra-operative instability. 
There is no compelling rationale presented, or extenuating circumstances noted to support the medical 
necessity of this request as an exception. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of arthrodesis have not been met. Therefore, we decided that the Plan does not 
have to pre-approve arthrodesis (22614).
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve destruction by neurolytic agent. 
 
You asked the Plan to pre-approve destruction by neurolytic agent. You say that this is medically necessary. 
The Plan denied your request. The Plan says this does not meet the LCD criteria for coverage. 
 
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 destruction by neurolytic agent. Our 
reviewer says that the service is not medically necessary. Our physician reviewer found the review has determined that the enrollee does not meet the criteria for the requested procedure. The requested procedure is 
not medically reasonable or necessary according to the coverage criteria established in the above LCD. 
 
We looked at this physician's review, the file, and Medicare rules. Based on this information, we decided that 
Medicare rules for coverage of destruction by neurolytic agent have not been met. Therefore, we decided that 
the Plan does not have to pre-approve destruction by neurolytic agent.
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 services are medically necessary. The Plan 
denied your request. The Plan says the enrollee does not meet the criteria for 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. 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: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to pay for a partial claviculectomy (23120) provided on April 5, 2023, 
by an out-of-network (OON) provider.  
   
You asked the Plan to pay for a partial claviculectomy with an out-of-network provider. You say that you want 
the Plan to pay for the service. The Plan denied your request. The Plan says prior authorization must be 
obtained prior to services being rendered from an out of network provider. Per the evidence of coverage, prior 
authorization is required for outpatient surgery.  
 
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. The Plan had network providers 
available who could have provided the items/services at issue in this appeal. 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 a partial claviculectomy (23120) provided on 
April 5, 2023, by an out-of-network (OON) provider.
Appeal type: ER
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the ED services provided on July 28, 2023. 
 
You asked the Plan to pay for the ED services. You say that this should be covered. The Plan denied your 
request. The Plan says Medicare payment cannot be made to this type of provider. 
 
The Plan follows Medicare rules. The rules say that freestanding EDs are not able to enroll in Medicare and 
cannot receive payment for services.  
 
We looked at the file and Medicare rules. We find that the provider at issue is not affiliated with a hospital and 
cannot receive Medicare payment.  Therefore, we decided that the Plan does not have to pay for the ED 
services provided on July 28, 2023.
Appeal type: Imaging
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a magnetic resonance imaging (MRI) of the lower 
spinal canal. 
 
You asked the Plan to pre-approve the MRI. You say that you have an old injury and are having pain that 
radiates down your right hip. The Plan denied your request. The Plan says you have not completed 6-weeks of 
provider directed treatments. 
 
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 the MRI. Our reviewer says that the 
MRI is not medically necessary. Our physician reviewer found the x-rays of the lumbar spine from August 19, 
2022, demonstrated chronic multilevel degenerative lumbar spondylosis and facet arthropathy, and rotatory 
lumbar dextroscoliosis. There are limited large-scale, long-term references showing the medical necessity of 
advanced imaging in this clinical scenario. There is no compelling rationale presented or extenuating 
circumstances noted to support the medical necessity of this request as an exception. Therefore, the requested 
magnetic resonance imaging (MRI) of the lower spinal canal 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 the MRI have not been met. Therefore, we decided that the Plan does not have 
to pre-approve a magnetic resonance imaging (MRI) of the lower spinal canal.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the traction equipment (E0849), provided on March 13, 
2023. 
 
You asked the Plan to pay for the traction equipment. You say that the item was medically necessary. The Plan 
denied your request. The Plan says the documentation requirements have not been met. 
 
The Plan must follow Medicare rules. The rules state that DMEPOS is covered only when there is a valid 
physician order, proof of delivery and relevant medical records which support medical necessity.  
 
The record does not contain relevant medical records which support medical necessity for the supplies provided in this case. The clinical records submitted do not indicate this item was needed or ordered. The record shows 
that the Plan made several attempts to obtain the necessary documentation without success. Therefore, we 
decided that the Plan does not have to pay for the traction equipment (E0849), provided on March 13, 2023.
Appeal type: Supplemental Benefit
Decision: Favorable

 
We decided that the Plan has to pay for the window replacement provided on April 22, 2023. 
 
You asked the Plan to pay for the window replacement. You say that you are requesting reconsideration since 
the reimbursement request for window replacement was denied and it is necessary. The Plan denied your 
request. The Plan says that the vehicle that underwent the glass replacement does not meet the necessary 
requirements to access this benefit, as it is a car model from the year 1990. The Plan also says the Medicare 
requirement is the vehicle needs to be from 2003 to comply with guidelines. 
 
The Plan must follow Medicare rules. The rules say that Medicare health plans must make reasonable and 
diligent efforts to gather and forward to the IRE information regarding its decision to deny coverage or 
payment. 
 
The Plan has not made reasonable and diligent efforts to gather and forward to us information regarding their 
decision to deny your request. We find that specifically, the Plan says that your vehicle was older than the 
required year of 2003 or younger for coverage to be allowed. The EOC does not say that you need to obtain 
prior authorization for coverage of supplemental benefits, nor does the EOC reference the criteria the Plan used 
to uphold this case. The Plan contract clearly states that up to one windshield replacement is covered per year. 
We cannot reasonably expect that you knew the vehicle needed to be from the year 2003 or later in order for 
the service to be covered, and you reasonably believed this window replacement would be covered. Therefore, 
we decided that the Plan has to pay for the window replacement provided on April 22, 2023.  
 
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 epidural steroid injections. 
 
You asked the Plan to pre-approve the injections. You say that the enrollee will be in pain for 3 months if they 
do not get the injections. The Plan denied your request. The Plan says epidural steroid injections 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 injections. Our reviewer says that 
epidural steroid injections are not medically necessary. Our physician reviewer found that the medical record 
does not document at least 50% of sustained improvement in pain relief and/or improvement in function 
measured from baseline using SAME scale for at least three months. Furthermore, the requested L4-L5 
epidural steroid injection will be performed using the same approach, level, and medication. Therefore, the 
enrollee does not meet the LCD coverage criteria. 
 
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 injections have not been met. Therefore, we decided that the Plan does not 
have to pre-approve epidural steroid injections.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the pneumatic compression device (E0675) provided on 
April 24, 2023, through May 17, 2023. 
 
You asked the Plan to pay for the pneumatic compression device. You say that the item was medically 
necessary. The Plan denied your request. The Plan says the item was not medically necessary. 
 
The Plan follows Medicare rules. The rules state that a PCD that provides intermittent limb compression for the 
purpose of prevention of venous thromboembolism (E0676) is a preventive service. The rules also say that a 
PCD coded as E0675 to treat peripheral arterial disease is not eligible for reimbursement. 
 We looked at the file and Medicare rules. Based on this information we decided that Medicare rules for 
coverage of the PCD have not been met. Specifically, this item is not a covered benefit of Medicare or the Plan. 
PCDs are not covered for preventions of venous thromboembolism nor for treatment of peripheral artery 
disease, regardless of how they are billed on the claim. Therefore, we decided that the Plan does not have to 
pay for the pneumatic compression device (E0675) provided on April 24, 2023, through May 17, 2023.
Appeal type: DME/ Orthotics
Decision: Unfavorable

 
We decided that the Plan does not have to pre-approve a home ventilator system. 
 
You asked the Plan to pre-approve a home ventilator system. The Plan denied your request. The Plan says a 
home ventilator is not medically necessary for this patient because their needs can be met with an alternative 
device such as a BiPAP device with average volume-assured pressure support (AVAPS).  
 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. Claims for ventilators used to provide CPAP or bi-level CPAP therapy will be denied as 
not 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 a home ventilator system. Our reviewer 
says that a home ventilator system is not medically necessary. Our physician reviewer found that the enrollee 
likely has carbon dioxide retention from chronic opiate use in the setting of aspiration event which developed 
pneumonia, hence improved with withdrawal of narcotics and BIPAP therapy while in hospital. However, the 
enrollee does exhibit signs of chronic respiratory failure but there is no indication that the patient has failed 
BIPAP or required increased level of support. 
 
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 home ventilator system have not been met. Therefore, we decided that the 
Plan does not have to pre-approve a home ventilator system.
Appeal type: Surgery
Decision: Unfavorable

 
We decided that the Plan does not have to reimburse you for the face down chair provided on February 2, 2023. 
 
You asked the Plan to reimburse you for the item. You say that you had eye surgery. You say that you had to 
hold your head down for 45 minutes each hour for 5 days. You also say that the chair had an apparatus to put 
your face in while you slept. The Plan denied your request. The Plan says this is not a covered benefit. 
 
The Plan must follow Medicare rules. Medicare rules say that durable medical equipment is equipment which 
is primarily and customarily used to serve a medical purpose, and generally, is not useful to a person in the 
absence of an illness or injury.  
 
We looked at the file and Medicare rules. Based on this information, we decided that Medicare rules for 
coverage of the item have not been met. Therefore, we decided that the Plan does not have to reimburse you for 
the face down chair provided on February 2, 2023.
Appeal type: Practitioner Services
Decision: Unfavorable

 
We decided that the Plan does not have to pay for immunization services provided on July 21, 2023. 
 
You asked the Plan to pay for immunization services. You say that you are requesting reconsideration for the 
denied claim. The Plan denied your request. The Plan says that this service is not covered under the Part B 
medical benefit. 
 
In the absence of injury or direct exposure to illness, Medicare does not pay for or provide immunization 
services. The Plan follows the same rules.  
 
Records do not show that you have been injured or directly exposed to any illness related to immunization 
services. Therefore, we decided that the Plan does not have to pay for immunization services provided on July 
21, 2023.  
 
Benefits for immunization services 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: Home Health
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the home health services provided from June 15, 2023, to 
July 14, 2023. 
 
You asked the Plan to pay for the home health services as billed. You say that the provider is home health 
certified. The Plan denied your request. The Plan says the claim has not been billed with the correct admission 
date. 
 The Plan follows Medicare rules. The rules say that for home health services that are continuing from 2021, a 
NOA must be submitted for the first period of care in 2022, using the first date of the period as the admission 
date. Subsequent claims must report this new date as the admission date in order for the claim to be matched to 
the correct NOA.  
 
We reviewed the file and the Medicare rules. We find that the admission date reported on the claim at issue 
does not match the date for the NOA 2022 as required. Based on this information, we find that the Medicare 
rules for payment of the claim at issue have not been met. Therefore, we decided that the Plan does not have to 
pay for the home health services provided from June 15, 2023, to July 14, 2023.
Appeal type: Supplemental Benefit
Decision: Unfavorable

 
We decided that the Plan does not have to pay for the dental services (D2740 and D2950) on July 19, 2023. 
 
You asked the Plan to pay for the dental services (D2740 and D2950). You say that you would like to request 
reconsideration for payment. The Plan denied your request. The Plan says your benefit for the requested item or 
service has already been exhausted. 
 
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, certain limitations apply. The record 
shows your benefit for the requested item or service was exhausted on date of service July 19, 2023. Therefore, 
we decided that the Plan does not have to pay for the dental services (D2740 and D2950) on July 19, 2023.
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 are requesting reconsideration of denied 
authorization. The Plan denied your request. The Plan says based on Medicare guidelines 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 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. 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 no 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.